Seminars in Spine Surgery - Articles in Press

Casting in Early-Onset Scoliosis - Corrected Proof

James O. Sanders, Charles E. Johnston, Jacques D'Astous — 2012-05-14

Derotational casting plays an important role in the management of early-onset scoliosis. It appears to be a potential cure in smaller curves, but it is an important surgical delaying tactic in a disorder where all surgical treatments have common complications. Proper casting technique is important and is delineated in this article.

Kyphotic Deformities in Skeletal Dysplasias - Corrected Proof

Eric D. Shirley, Michael C. Ain — 2012-05-14

Nearly all skeletal dysplasias have spinal manifestations, for example, kyphosis, scoliosis, and vertebral anomalies. Kyphosis may occur in the cervical and thoracolumbar spines or in association with severe scoliosis. Cervical kyphosis may occur in patients with diastrophic dysplasia or Larsen syndrome. Large kyphoses with progression or neurologic symptoms require surgery, but most patients with diastrophic dysplasia will show resolution. Thoracolumbar kyphosis occurs in nearly all patients with achondroplasia, but resolution is common, occurring when walking begins. Persistent kyphoses may exacerbate coexisting spinal stenosis; curves with progression or neurologic compromise may require arthrodesis with instrumentation.

Introduction - Corrected Proof

Jeffrey A. Rihn, Alexander R. Vaccaro — 2012-05-14

Injuries to the thoracolumbar spine represent some of the most challenging problems that are encountered by spine care providers. The degree of injury can vary from a simple vertebral body compression fracture in a neurologically intact patient to an unstable flexion-distraction injury in a patient with a complete neurological deficit. Unstable thoracolumbar injuries typically result from high-energy trauma, such as a motor vehicle crash or a fall from height. Victims of such trauma frequently have concomitant injuries to other organ systems that can be life threatening. The care of these patients begins in the field and the trauma bay, with appropriate management of the airway and circulatory system, fluid resuscitation, and spine precautions.

Vertical Expandable Prosthetic Titanium Rib in Early-Onset Scoliosis - Corrected Proof

Odion Binitie, John M. Flynn — 2012-05-11

In the past decade, pediatric spine surgeons have widely adopted repetitive distraction strategies (vertical expandable prosthetic titanium rib [VEPTR] and growing rods) to manage severe spinal deformity in young children. An increasing body of evidence shows that spine deformity can be successfully controlled until the onset of puberty; spinal length increases and the inexorable pulmonary decline can be halted, and even improved, in most children. VEPTR has many advantages over spine-based growing rods in the management of early-onset scoliosis: Food and Drug Administration approval, limited spinal exposure, chest wall expansion capabilities, easier lengthening, and easier management of the inevitable complications, such as infection and anchor fixation loss. Now that the Food and Drug Administration approval with humanitarian device exemption is complete, engineering modifications will make VEPTR more versatile, especially for conditions such as kyphosis and secondary chest wall collapse.

Growing Rods in Early-Onset Scoliosis - Corrected Proof

Matthew E. Oetgen, Laurel C. Blakemore — 2012-05-07

Early-onset scoliosis refers to scoliosis that present in children aged <5 years. This subset of scoliosis represents a heterogeneous group with a variety of etiologies, types of curves, and curve behavior patterns. In general, the goals of treatment include control of the spinal deformity, preservation of spinal growth, and encouragement of normal lung and chest wall development. Growing rods have evolved into an effective and safe treatment option for children with early-onset scoliosis. Appropriate patient selection, optimal construct design, and regular patient follow-up are essential to optimize outcome while limiting complications with this treatment modality.

Introduction - Corrected Proof

Brian G. Smith — 2012-04-27

The management and treatment of spinal deformity in children and adolescents has long been at the very core and indeed is essentially the founding basis of orthopedic surgery. The challenge of managing spinal deformity has intrigued physicians since the days of Hippocrates. In our current modern era, insights and knowledge gained from advances in basic science and genetics now enable orthopedic surgeons caring for scoliosis in children to have a better understanding of the natural history and outcome of these disorders. In addition, the continued development of new technology and innovative techniques now provide the surgeon the opportunity to manage and guide growth of the spine in children as part of the treatment of these often difficult spinal deformities.

The Legal Ramifications of Spinal Care Medical Malpractice and Its Implications for Spinal Surgery - Corrected Proof

James Ghadially — 2012-01-30

A brief review of the conflicting desires of a medical profession's desire to be relieved of the burden of malpractice litigation in the context of the constitutional framework of the American legal systems has been conducted. The limits of restricting the rights of the citizen are addressed. The aim of this review is to provide a primer on the realities relating to the constitutional rights of the American citizen and the constructive purpose that litigation is believed to provide society. A review of available case law and learned treaties was undertaken to provide an insight into the workings of the legal system pertaining to issues of most interest to the spine community. The current legal system walks the fine line between protecting the public and their constitutional rights and ensuring that the delivery of medical care is not unduly impacted. It is the author's opinion that each specialty can positively affect the decisions of the courts by providing firm guidance as to what is and is not the “standard of care,” thus preventing fallacious expert testimony from reaching the jury.

Spinal Care: What Measurements Should be Used to Define Value to Society? - Corrected Proof

Kathryn J. McCarthy, Leah Y. Carreon, Steven D. Glassman — 2012-01-24

Evidence-based approaches to the treatment of spinal pathology are needed as the field evolves. Patient-reported outcomes have become the standard by which therapeutic success is defined. There are 4 types of commonly used outcome measures: generic, disease specific, pain scales, and health utilities. Using this framework to evaluate outcomes allows for cost-effectiveness studies to be done and define the value of spinal care to society.

Defining the Value of Spine Care to Society - Corrected Proof

Christopher K. Kepler, Jeffrey A. Rihn, Alexander R. Vaccaro, Todd J. Albert — 2012-01-03

Defining value in spine surgery increasingly considers the patient's perspective, a task that requires quantifying outcomes using validated, patient-derived outcome instruments. Both general and disease-specific instruments have been used to measure outcomes after spinal surgery. Some outcomes instruments can be used to derive a utility score, a metric that grades patient health along a continuous spectrum from 0 to 1. The change in utility score after a procedure and the procedure cost are used to determine the cost per change in utility, a measurement that forms the basis of cost-effectiveness analysis and can be compared between procedures.

Spinal Care in a Single-Payer System: The Canadian Example - Corrected Proof

Raja Rampersaud, Kevin Macwan, Nizar N. Mahomed — 2012-01-03

This article provides a general understanding of the fundamental differences between the Canadian and United States health care systems and how they may relate to spine care. Issues regarding sustainability of either system are beyond the scope of this article. The Canadian perspective is presented in this article. These 2 systems are fundamentally different regarding universality and accessibility of health care coverage and delivery. Comparative studies for a variety of health states, including spinal disorders, do not show significant differences in outcomes between countries for those who are insured. Consequently, the pro's and con's of both systems are variable depending on the perspective taken.

Social and Legal Ramifications of Spine Care: The Challenges - Corrected Proof

David A. Wong, Katherine E. Wong — 2011-12-30

Challenges abound in our quest to define the “Social and Legal Ramifications of Spine Care.” These challenges exist not only in regards the present-day practice of spinal surgery but particularly with regard to delineating the “value” of spinal treatments to patients and society as a whole as healthcare reform is implemented in the United States. The principles of comparative effectiveness research (CER) have been adopted as parameters for measuring “value” in healthcare reform legislation. The CER approach uses economic analyses such as cost-effectiveness to deduce whether a particular intervention will be reimbursed. The conclusion of a cost-effectiveness analysis will be generally expressed as a cost (in $, €, £, etc) per patient gain in quality-adjusted life year (QALY). The National Institute for Health and Clinical Excellence in the United Kingdom has set a threshold of £30,000 (approximately 50,000 US dollars) per QALY gained as a ceiling for recommending a procedure be reimbursed under the UK National Health Service. No definite criteria have been set in the United States. Defining the value of spine care to society has a number of unresolved issues. These include who should define value (patients, physicians, government), how should we measure value (CER, clinical outcomes, direct cost only vs including indirect costs), and how much is society willing to pay for spine care ($50,000 per QALY as in the United Kingdom or should it be more in the United States). We will define many of these issues in the challenges article and leave subsequent authors in this issue to expound the details so that readers have a greater understanding of the challenges faced by us all in terms of defining the societal value of spine care. The final challenge, of course, is applying the value principles in a practice environment where many clinical decisions are influenced by legal ramifications. Important information for practitioners will be imparted in the final article of this issue.

Who Should Define Value in Spine Care? - Corrected Proof

Charles Mick — 2011-12-30

Ideally, each patient should be provided with accurate information on outcome and cost and select care based on the best value and personal care preferences. Unfortunately, useful information on outcome is often absent or equivocal, and information on cost is obscured by the design of our health care system. Numerous efforts are underway to better empower patients in decision-making and support patient-centered research. Comparative effectiveness studies and patient registries will generate new information and may help to define value. Techniques for measurement of cost will need to be refined and more commonly used. While these efforts are progressing, medical societies, the government, and insurers have developed standardized methods to collect and analyze the current literature and make recommendations for care they believe valuable and appropriate. Clinical care guidelines, health technology assessments, meta-analysis, and appropriateness criteria are some of the structured methods for assessing the current evidence. These clinical care recommendations are useful but are incomplete and inadequate in defining value because of the absence of information on cost and the limited information on outcomes.

Introduction - Corrected Proof

David A. Wong — 2011-12-30

It is an honor to be the Guest Editor for this issue of Seminars in Spine Surgery with the theme of “Social and Legal Ramifications of Spine Care.” We have assembled a stellar group of authors with specific topic expertise to write papers outlining some of the key issues in this subject area.

Defining Appropriate Spine Care for the Patient as well as Society - Corrected Proof

2011-12-30

In this era of constrained resources, spine care professionals are challenged to provide value and justification of resource allocation. For surgeons, this requires demonstration of clinical superiority that is both significant and durable compared with nonsurgical management and/or with other forms of surgical treatment. Value concepts such as the cost per quality-adjusted life year allow for more objective comparisons of treatment both for the same condition and for different conditions across a variety of disciplines. It thus becomes imperative that these concepts are learned and used in the design of future studies in the treatment of spinal disorders.